New Albany Health & Rehab Center

Inspectors wroteBased on observations, interview, and facility policy review, the facility failed to label and store food properly for one (1) of three (3) kitchen tours. Findings Include: Review of facility policy titled Food Storage with a revision date of 11/28/2017 revealed, Ready-to-eat foods shall be marked with a discard date at the time of opening or preparation. During the initial tour of the kitchen with the District Dietary Manager (DM) on 6/8/2026 at 10:10 AM, the walk-in freezer was observed to have open boxes of corndogs, chicken patties, and mixed vegetables exposed to the air. In the walk-in refrigerator, a gallon milk jug that was about one-fourth (1/4) full had no date indicating when it was opened. In the dry storage room, one-third (1/3) of a bag of spaghetti noodles and one-half (1/2) of a five-pound bag of egg noodles were open and exposed to the air. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to follow the resident's comprehensive care plan for grooming preferences for two (2) of (21) care plans reviewed. Resident #11 and Resident #65.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide grooming assistance related to shaving unwanted facial hair for two (2) of (103) residents reviewed for activities of daily living (ADLS) during the initial tour. Residents #11 and #65 Findings Include: Review of the facility policy titled Activities of Daily Living revised 9/15/22 revealed under, Policy: . Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming, and oral care; Additionally revealed under, Policy Explanation and Compliance Guidelines: . 3. Residents who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. [...]

Inspectors wroteBased on record review, facility policy review, staff interviews, and resident representative interviews, the facility failed to ensure binding arbitration agreements were presented and explained in a form and manner understood by resident representatives and failed to ensure resident representatives (RR) were informed that signing the arbitration agreement was voluntary and not a condition of admission for two (2) of three (3) residents reviewed for arbitration agreements. Residents #27 and #92Findings Include:Review of the facility policy titled Binding Arbitration Agreement revealed under, Policy: This facility asks all residents to enter an agreement for binding arbitration. Additionally revealed under, Policy Explanation and Compliance Guidelines: 1. When the arbitration agreement is presented: a. [...]

Inspectors wroteBased on observations, staff interview, record review, and facility policy review, the facility failed to ensure reasonable accommodation of resident needs by maintaining access to the call system for one (1) of (21) residents reviewed. Resident #62.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to obtain a physician-ordered laboratory test for one (1) of five (5) residents reviewed for medication management and laboratory services. Resident #63. Findings Include:Review of the facility policy titled Diagnostic Services: Lab Tests and X-Ray with a revision date of 11/28/2017, revealed, It is the policy of this facility to provide or obtain radiology and other diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services. Review of Resident #63's Order Details with a Physician's order date of 12/24/2025, revealed under Description: [...]

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review the facility failed to implement a comprehensive care plan for Activities of Daily Living (ADL) for two (2) of 18 sampled residents. Resident # 57, and #62 Findings Include: Review of the facility's policy titled, COMPREHENSIVE PLAN OF CARE with a revision date of 2/17/2025, revealed under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality . [...]

Inspectors wroteBased on observation, staff and resident interviews, record review and facility policy review the facility failed to ensure resident's requiring assistance with Activities of Daily Living (ADL) were given care as they needed to maintain hygiene for two (2) of 18 sampled residents.

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review the facility failed to ensure an environment that is free from accident hazards and the safety of a resident during care for one (1) of 18 sampled residents. Resident #31 Findings Include: Review of the facility policy titled, INCIDENT AND ACCIDENT REPORTING, with a revised date of 9/05/2023, states It is the policy of this facility that everything possible should be done to avoid accidents or incidents involving patients .Proper reporting helps correct the current incident and prevent future incidents like it . An observation and interview on 06/23/25 at 10:30 AM with Resident #31, revealed a bandage on her right arm. Resident #31 stated, The aide scratched me with her nails when she was giving me care. [...]

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review the facility failed to utilize Personal Protective Equipment (PPE) for a resident (Resident #188) who was under contact isolation on one (1) of three (3) survey days. Findings Include: Review of the facility policy Infection Prevention and Control with revision date of 02/17/25 revealed, This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines . An observation on 06/23/25 at 9:36 AM, revealed Certified Nursing Assistant (CNA) #1 enter Resident #188's room to answer her call light without utilizing Personal Protective Equipment (PPE). [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to develop a baseline care plan to include the initial plan of care for delivery of services and to promote continuity of care and communication for facility staff for a newly admitted resident with a known history of eloping from home prior to admission for one (1) of three (3) care plans for residents who were at risk for elopement. Resident #1 Resident #1 left the facility unnoticed and unsupervised at an unknown time on 04/26/24 and was discovered by the local police department at a nearby business approximately 75 yards from the facility. This business notified the police at 5:38 PM and the resident was found by police at 6:01 PM and was returned to the facility. Resident #1 was last observed on 4/26/24 at 4:38 PM in his room, prior to the elopement. [...]

Inspectors wroteBased on observation, staff and family interview, record review and facility policy review the facility failed to supervise and prevent the elopement of a resident who was identified at risk for elopement as evidenced by the resident leaving the facility unnoticed and unsupervised and walking 75 yards to a local business for one (1) of three (3) at risk residents reviewed for elopement. Resident #1 Resident #1 was admitted to the facility on [DATE] at 3:21 PM. Resident #1 left the facility unnoticed and unsupervised at an unknown time on 4/26/24 and was discovered by the local police department at a nearby business. This business notified the police at 5:38 PM and the resident was found by police at 6:01 PM and was returned to the facility. Resident #1 was last observed on 4/26/24 at 4:38 PM in his room, prior to the elopement. [...]

Inspectors wroteBased on staff and resident interviews, record review and facility policy review, the facility failed to resolve a grievance of missing clothing for six (6) of 11 residents reviewed for grievances. Resident #9, Resident #28, Resident #39, Resident #47, Resident #54, and Resident #66. Findings Include: Record review of the facility policy titled Conflict Resolution and Resident Complaint and Grievance Process with a revision date of 09/06/2022 revealed under, Complaints and Grievances: . If a grievance is not resolved, the investigation is not complete, or if the corrective action is still being evaluated within the seven (7) day timeframe, the facility shall send a response to the resident stating that the facility continues to work to resolve the complaint and the facility shall follow-up with another response within 24 hours. [...]

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review the facility failed to provide privacy for a resident with a urinary catheter as evidence by no privacy bag covering the urine drainage bag for one (1) of four (4) residents with catheters reviewed. Resident # 79 Findings Include: Record review of facility policy titled Resident Rights dated 2020, revealed, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 7. Privacy and confidentiality. a. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. a. Personal privacy includes accommodations, medical treatment .personal care . [...]

Inspectors wroteBased on staff interviews, record review and facility policy review, the facility failed to complete a thorough investigation for one (1) of three (3) residents with incidents reviewed. Resident #27 Findings Include: Record review of the facility policy titled Incident and Accident Reporting with a revision date of 9/05/2023 revealed under, Policy: . It is important that the incident and accident report and investigation be completed timely and thoroughly to ensure an accurate record of the event . Record review of the Incident Note dated 11/24/23 at 2:34 PM revealed, Resident noted sitting in floor with back against w/c (wheelchair) wheels locked on w/c (wheelchair) cushion was under resident able to move upper ext (extremities) without pain. c/o (Complains of) back et hip pain et ambulance services called at this time. No other injuries noted at this time. [...]

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to implement a comprehensive care plan for monitoring of side effects of an anticoagulant (Resident #15) and to provide a privacy bag on a urinary catheter bag (Resident #79) for two (2) of 21 resident care plans reviewed. Resident #15 and Resident #79 Findings Include: Record review of facility policy titled, Comprehensive Care Plan dated 10/10/22, revealed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The comprehensive care plan will describe, at a minimum, the following: a. [...]

Inspectors wroteCross Refernce F759 Based on observation, staff interview, record review and facility policy review the facility failed to administer resident medications based on professional standards of practice for 10 of 36 medication administration opportunities.

Inspectors wroteBased on staff interviews, record review and facility policy review the facility failed to monitor for the side effects of an anticoagulant (blood thinner) for one (1) of five (5) resident medication reviews. Resident #15 Findings Include: Record review of the facility policy titled High-Risk Medication - Anticoagulants with a revision date of 12/22/2022 revealed under, Policy: This facility recognizes that some medications, including anticoagulants, are associated with greater risks of adverse consequences than other medications. Also revealed under, Policy Explanation and Compliance Guidelines: . 4. The resident's plan of care shall alert staff to monitor for adverse consequences . [...]

Inspectors wroteCross Reference F658 Based on observation, staff interview, record review, and facility policy review the facility failed to maintain a medication error rate of less than 5% by ensuring that residents received all physician-ordered medications for 10 of 36 medication administration opportunities observed during medication pass. The medication error rate was 27.78%.

Inspectors wroteBased on observation, staff and resident interview, record review and facility policy review the facility failed to honor a resident's food choice for one (1) of three (3) residents reviewed. Resident #17 Findings Include: Review of the facility policy titled, Resident Rights and Responsibilities with a revision date of 10/10/22 revealed .5. Self Determination .b. The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . An observation and interview on 12/04/23 at 11:39 AM, with Resident #17 stated she does not like rice, and they keep serving her rice. An observation of the resident's lunch tray revealed the resident had rice served on her tray and her meal ticket revealed that rice was a dislike. [...]

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to send a written notice of transfer or discharge for three (3) of three (3) residents with transfer or discharges reviewed. Resident #2, Resident #30 and Resident #62 Findings Include: Record review of facility policy titled Transfer and Discharge dated 10/18/22, revealed, The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. This notice will include all of the following at the time it is provided: a. The specific reason and basis for transfer or discharge. During an interview on 12/5/23 at 1:15 PM, the Administrator confirmed the facility was not sending a written notice of transfer with the reason for the transfer to the resident or to the resident's representative. [...]